The number of patients with colorectal cancer had increased dramatically in recent years (Hong Kong cancer registry, 2012), and surgical resection is the first line treatment of colorectal. To enhance patients’recovery process, there is a need to develop a comprehensive and user-friendly, with most important, an evidence-based guideline for promoting patients’ recovery process. Traditional post-operative management is associated with different postoperative complications, delayed recovery, and lengthened hospital stay. Recent research documented that using a specific rehabilitation programme focused on education; early mobilization and early diet regime could enhance patients’ recovery. Therefore, this transitional research aims to evaluate the current evidence on the effect of adopting a specific rehabilitation programme, to formulate an evidence-based guideline, assess its implementation potential, and to develop an implementation and evaluation plan. Ten related literature were retrieved from four electronic bibliographical databases. Critical appraisal had been done to ensure the quality and validity of the selected evidences. A clinical guideline is developed based upon the information from the identified high level of literature. The implementation potential is assessed based on the similarity and the readiness of the target setting to the proposed environment. It was found that the transferability of the protocol was high and it was feasible to be implemented into the target site. Little expenditure and input was expected, as the protocol was a systematic reformation of practice, rather that developing a set of totally new practice to current clinical setting. An implementation plan was then planned, which included the communication plan with all the stakeholders. After reaching a consensus among the stakeholders, a two-month pilot study will be carried out for examining the readiness before the full-scale implementation of the program. The evaluation plan of the effectiveness of the proposed program is developed. Result will be used to provide recommendation for further adjustment on the protocol to yield a better outcome. The implementation of this nurse-led rehabilitation program is suggested to be worthy of adoption in the clinical setting for bringing benefits to patients, the hospital and staffs. / published_or_final_version / Nursing Studies / Master / Master of Nursing

Substantial studies have investigated homogeneity of psychological distress level among cancer patients by using cross-sectional and longitudinal study design. Nonetheless, as proposed by Bonnano (2004), heterogeneity characteristics of psychological distress following stressful event could not be neglected and he further suggested that the majority of individuals were resilient in response to stressful events. To test this postulation, recent studies employed growth mixture modelling method to examine the heterogeneity characteristics of psychological distress trajectory among cancer patients. Furthermore, identifying relevant factors differentiate the psychological distress trajectories is an integral part for developing effective interventions for cancer patients in dealing with illness demands. However, only a few studies have examined these issues among Chinese colorectal cancer patients, a second most common cancer in Hong Kong. Therefore, it is of important need to address this knowledge gap. This study had two major aims: 1) to explore the patterns of psychological distress among Chinese patients with colorectal cancer from shortly after diagnosis but before surgery (i.e. 1-day prior operation) to 1-year post-surgery and to testify Bonnano’s theory on resilience; 2) to identify the effects of cancer-related intrusive thoughts, physical symptom intrusiveness and dispositional optimism on differentiating psychological distress trajectories. A total of 246 Chinese patients with colorectal cancer were recruited for the current study. Altogether, 5 consecutive face-to-face interviews were conducted on one day prior to surgery (baseline), 1-, 4-, 8- and 12-month post-surgery (T2-T5). Patients’ psychological distress (i.e. anxiety and depression), physical symptom intrusiveness, cancer-related intrusive thoughts, dispositional optimism, demographic and medical information were assessed by a standardised questionnaire with valid and reliable psychometric instruments. Growth mixture modelling was used to estimate and specify the psychological distress trajectories. Multinomial logistic regression was adopted to assess the proposed factors in relation to differentiate the trajectory patterns. Growth mixture modelling suggested three distinct trajectories were identified for both anxiety and depression model. The majority of patients with colorectal cancer were identified as resilient (i.e. maintaining low and stable distress level across time) for both models (anxiety: 82.3%, depression: 82.7%). Additionally, for anxiety trajectory model, the remaining 12.3% and 5.4% of patients were classified as moderately-low anxiety group (i.e. maintaining moderate to low distress level) and increasing anxiety group (i.e. increased from moderate level of distress at initial to subsequently high distress level) respectively. For depression trajectory model, the remaining 12.6% and 4.7% of the patients were grouped as delayed depression (i.e. delayed level of distress over time) and recovery depression (i.e. recovered from high distress level to low across time). Multinomial logistic regression showed that cancer-related negative intrusive thoughts, physical symptom intrusiveness and dispositional optimism were significant factors to differentiate anxiety and depression trajectories respectively. This study highlighted the heterogeneous feature of psychological distress among Chinese patients with colorectal cancer. Physical symptom intrusiveness, cancer-related negative intrusive thoughts and dispositional optimism played important role on predicting cancer patient’s psychological distress respectively. Nonetheless, further investigations are much needed to clarify the underlying mechanism. / published_or_final_version / Public Health / Master / Master of Philosophy

published_or_final_version / Medicine / Master / Master of Medical Sciences

Colorectal cancer has been a major health issue worldwide. Not only it affects the patients but it also carries physical and psychological influences to their caregivers. Despite the concerns of the psychological needs of caregivers of colorectal cancer patients, there has been a lack of a good understanding of their needs, and how to intervene in order to alleviate their psychological problems and burdens. Therefore, this thesis aimed at designing and evaluating a nurse-led telephone based psychosocial education program for improving the psychological conditions and quality of life among Chinese caregivers of patients with colorectal cancer. The nurse-led telephone based psycho-educational program was designed based on the transactional model of stress and copying. It was piloted on 6 caregivers and refined. Its efficacy over the patients discharged under the ‘usual routine hospital standard discharge care procedure’ was assessed in a randomized controlled trial on 140 Chinese caregivers of colorectal cancer patients. Caregivers in the intervention group received three telephone calls from an experienced Nurse Interventionist at 1, 3 and 5 weeks after the patients’ discharge. Each call addressed any unmet needs of the caregivers with the provision of education and psychological support. At baseline, 2 weeks, 4 weeks and 8 weeks, all caregivers were assessed for the primary outcome of depression measured by the Depression Anxiety Stress Scale (DASS), and for the secondary outcomes of anxiety, stress, burden of care and quality of life. The mixed effects model, which takes into account the extra-covariance among repeated measurements, and which is consistent with the intention-to-treat principle, was used in the efficacy analysis. Of the 140 caregivers recruited in the randomized controlled study, 5 dropped out before the end of the study. However, all the caregivers were included in the analysis. There was no significant baseline difference between the intervention and ‘usual care’ groups. The psycho-education program reduced depression more than the ‘usual care’ group by2.7 (95% CI = 0.6 to 4.8, p=0.013) units in DASS at 2 weeks, and even more by 3.5 (95% CI = 1.7 to 5.24, p<0.001) at 4 weeks. However, the ‘usual care’ group caught up at 8 weeks, and no significant effect of the psycho-education program was found (p=0.144). Moreover, the program also reduced anxiety and stress more than the ‘usual care’ group by1.83 (95% CI = 0.61 to 3.50, p=0.004) and 3.50 (95% CI = 1.74 to 5.25, p<0.001) respectively at follow-up. In addition, the burden of care and quality of life were also generally improved more in the psycho-education program group. Furthermore, strong positive associations among depression, stress, anxiety, and burden of care were found. Caregivers perceived to have a high burden of care would be associated with more depression, stress or anxiety(r = 0.53, p<0.001). Moreover, depression, anxiety, and stress had a strong negative association with the physical, psychological, social relationship and environmental well-being but not with social relationships(r = -0.16, p = 0.550). In conclusion, this thesis has developed the first nurse-led telephone based psycho-education program for caregivers of colorectal cancer patients. The program can effectively help caregivers in reducing their feelings of stress from depression, anxiety, stress and the burden of care, as well as improving their quality of life. It paves the way for a new direction for a comprehensive colorectal cancer care service in addressing the caregivers’ needs. / published_or_final_version / Nursing Studies / Doctoral / Doctor of Nursing

published_or_final_version / abstract / Community Medicine / Doctoral / Doctor of Philosophy

Increasing number of people is diagnosed with colorectal neoplasms (CRN) in the form of polyps or cancers. Colorectal cancer (CRC) is one of the most common causes of cancer deaths among Chinese in Hong Kong. Advances in diagnosis and treatments have increased the survival rate of CRN patients, resulting in a large group of cancer survivors. Preserving and maintaining health-related quality of life (HRQOL) has become an important direction in research and clinical care of patients with CRN. This research aimed to evaluate the HRQOL and its association with socio-demographics and disease-related characteristics among patients with CRN, and illustrate how HRQOL data could be converted to preference for the estimation of quality adjustment of life years in health economic evaluations. This research comprised of three parts. First was the establishment of the validity and reliability of the traditional Chinese version of Functional Assessment of Cancer Therapy-Colorectal (FACT-C) as a HRQOL measure for Chinese patients by a cross-sectional sample of 536 adult patients with CRN. Psychometric testing and concurrent validation of the FACT-C with European Organization for Research and Treatment of Cancer Core Questionnaire plus Colorectal-specific Module Questionnaire and the Short-Form 12-item Health Survey_Version2 (SF-12V2) were carried out. Second was a longitudinal study on the HRQOL of 554 CRN patients at baseline, six (n=479) and twelve (n=414) months of recruitment. The associations of HRQOL with socio-demographics and disease-related factors, and change of HRQOL over time were explored. Comparisons of HRQOL between CRN patients and the general population and among different CRN groups were made. Cross-sectional data were used to develop mapping functions to estimate SF-6D preference scores from FACT-C subscale scores. Third was the application of the health preference scores by CRN stages collected at baseline of the longitudinal study, in combination with survival data extracted from the literature in a Markov model on the cost-effectiveness of different CRC screening strategies (colonoscopy, guaiac and immunochemical fecal occult blood tests) in comparison to no screening in terms of quality-adjusted life-years gained. This research comprised of three parts. First was the establishment of the validity and reliability of the traditional Chinese version of Functional Assessment of Cancer Therapy-Colorectal (FACT-C) as a HRQOL measure for Chinese patients by a cross-sectional sample of 536 adult patients with CRN. Psychometric testing and concurrent validation of the FACT-C with European Organization for Research and Treatment of Cancer Core Questionnaire plus Colorectal-specific Module Questionnaire and the Short-Form 12-item Health Survey_Version2 (SF-12V2) were carried out. Second was a longitudinal study on the HRQOL of 554 CRN patients at baseline, six (n=479) and twelve (n=414) months of recruitment. The associations of HRQOL with socio-demographics and disease-related factors, and change of HRQOL over time were explored. Comparisons of HRQOL between CRN patients and the general population and among different CRN groups were made. Cross-sectional data were used to develop mapping functions to estimate SF-6D preference scores from FACT-C subscale scores. Third was the application of the health preference scores by CRN stages collected at baseline of the longitudinal study, in combination with survival data extracted from the literature in a Markov model on the cost-effectiveness of different CRC screening strategies (colonoscopy, guaiac and immunochemical fecal occult blood tests) in comparison to no screening in terms of quality-adjusted life-years gained. Psychometric analysis confirmed that FACT-C had satisfactory reliability, construct validity and responsiveness in Chinese patients Patients with CRN reported worse physical HRQOL but better mental HRQOL and similar health preference score compared to the general population. Disease severity indicated by tumor stage at initial diagnosis was the most significant determinant of HRQOL of CRN patients. Rectal cancer also significantly associated with a decrease in physical HRQOL and health preference scores. Markov modelling showed that immunochemical fecal occult blood (I-FOBT) yearly was the most effective and two-yearly was the most cost-effective screening strategy compared to no screening. / published_or_final_version / Family Medicine and Primary Care / Doctoral / Doctor of Philosophy